Discussion

Following the shameful worldwide withdrawal of Drotrecogin Alpha, it seems unlikely that the candidates would ever be expected to "write short notes" on it in the ultra-pragmatic CICM fellowship exam. Thus, I will leave the discussion of its merits and demerits to the historians. Moreover, given the changing nature of the fellowship exam (trending further towards easy-to-mark data interpretation questions and tabulated comparisons), it is unlikely the candidates will ever be asked to write short notes on any topic whatsoever.

Recombinant Factor VIIa remains a possibly examinable topic. One might someday be expected to tabulate its advantages and limitations, or to critically evaluate its use.

Thus:

Rationale

Factor VIIa is thought to act locally, binding to exposed tissue factor at the site of injury and promoting plateet binding.

Currently, in Australia the recombinant Factor VIIa is licenced for use only in the treatment of bleeding in patients with haemophilia A and B, who have a circulating inhibitor of the coagulation factor.

Multiple guidelines for the off-licence use of this drug have emerged.

After reviewing the available evidence, J.L Vincent's group have suggested that Factor VIIa can be used blunt trauma, post-partum hemorrhage, uncontrolled bleeding in surgical patients, and bleeding after cardiac surgery.

Surgical haemostasis needs to have been achieved, say the haematologists who in Australia act as the curators of our FVIIa supplies. However, it is not clear that this is a mandatory component. The Israeli guidelines (Martinowtz et al, 2005) specifically include as one of their indications "Failure to arrest the hemorrhage despite... application of all accepted and available surgical measures (e.g. ligation of damaged vessels, tamponading, or packing of the bleeding site, and induction of localized thrombosis)". In short, surgical haemostasis is viewed by some to be a contraindication to the use of FVIIa. In contrast, the 2006 European guidelines (Vincent et al, 2006) recommend that "rFVIIa should be used only as an adjunctive therapy to surgical control", and there is some data that some intervention to control the haemorrhage improves mortality (Payen et al, 2016)